New Patient Registration Form

Please complete the form below, and press the Enroll button.

    Personal Details


    Home Address


    Postal Address


    Contact Details


    Medicare Details


    DVA Gold/White


    Pension or Health Care Card Details




    Next of Kin


    Emergency Contact


    Personal Details


    Stratford Medical Centre and Wheels of Wellness participate in Quality Improvement involving the sending of de-identification information for Health Data. Please inform reception if you do not wish to participate.


    Privacy

    Your medical record is a confidential document. It is always the policy of this practice to maintain the security of personal health information and to ensure that this information is only available to authorised members of staff.

    Please refer to our Privacy Policy located at Reception or via our website.


    Consents

    Do you consent to the Doctors at Stratford Medical Centre uploading and accessing your My Health Record?
    Yes
    No
    Do you wish to receive SMS notifications from Stratford Medical Centre for the following?
    Yes
    No
    Yes
    No
    Yes
    No
    Yes
    No
    Do you consent to the Staff at Stratford Medical Centre sending Emails to you which may contain private/clinical information?
    Yes
    No

    If you request to communicate with us via email, we remind you that this is not encrypted, and we do not send information via this means, without your consent.

    Digital Signature
    Date